CASE REPORT Brucellar Testicular Abscess Case Presenting as a Testicular Mass: Can Color Doppler Sonography Be Used in Differentiation? Testiküler Kitle Şikayetiyle Gelen Brusellar Testiküler Apse Olgusu: Renkli Doppler Sonografi Ayırıcı Tanıda Kullanılabilir mi? Furkan KAYA,1 Ali KOCYIGIT,1 Cihan KAYA,1 Ibrahim TURKCUER,2 Mustafa SERINKEN,2 Nevzat KARABULUT1 1 Department of Radiology, Pamukkale University Faculty of Medicine, Denizli; Department of Emergency Medicine, Pamukkale University Faculty of Medicine, Denizli 2 SUMMARY ÖZET Brucellosis is an endemic disease in various regions of the world. Testicular abscess is a very rare complication of brucellosis which can be misdiagnosed as testicular mass and leads to unnecessary orchiectomy. To our knowledge there are only eight reported cases in the literature with a brucellar testicular abscess. We present a case of testicular abscess due to brucellosis diagnosed with serologic tests and color Doppler sonography, and treated with antibiotics and fine needle aspiration. Brusellozis dünyanın değişik yerlerinde olan endemik bir hastalıktır. Testiküler apse brosellozisin son derece nadir bir komplikasyonu olup testiküler kitle olarak tanı alabilir ve gereksiz orşiektomiye yol açabilir. Bildiğimiz kadarıyla literatürde brusellar testiküler apseli sadece sekiz vaka bildirilmiştir. Biz burada serolojik testler ve renkli Doppler sonografi ile tanısı konulan ve antibiyotik ve ince iğne aspirasyonu ile tedavisi yapılan brusellozise bağlı testiküler apse olgusunu sunuyoruz. Key words: Abscess; brucellosis; color Doppler sonography; testicular; ultrasonography. Introduction Brucellosis is an endemic, zoonotic disease in some regions of the world and affects some organs and tissues in human. Direct contact with infected animals or ingestion of contaminated animal products are routes of transmission to humans.[1,2] Brucellar orchi-epididymitis is a complication of systemic brucellosis in human and can be seen in 5.7% of affected patients. Brucellar testicular abscess can be misdiagnosed as necrotic testicular mass leading to unnecessary orchiectomy.[3-8] Thus the diagnosis of abscess is of critical importance to avoid the testicular loss in these patients. We present a 23-year-old man with a brucellar testicular abscess Anahtar sözcükler: Apse; brusellozis; renkli Doppler sonografi; testiküler; ultrasonografi. which was diagnosed with color Doppler sonography findings, and treated with drainage and administration of combined antibiotic therapy. Case Report A 23-year-old male patient was admitted to Emergency Department due to right testicular swelling for 2 months. The patient declared that he was prescribed gentamycine 1x100 mg in 7 days by a family physician one month before his admission, but his complaints continued. The patient had no history of direct contact with infected animals but had a history of relatively recent ingestion of unpasteurized Submitted: January 23, 2014 Accepted: February 16, 2014 Published online: June 2, 2014 Correspondence (İletişim): Dr. Ali Koçyiğit. Pamukkale Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Denizli, Turkey. e-mail: [email protected] Turk J Emerg Med doi: 10.5505/1304.7361.2014.82698 Turk J Emerg Med cheese. Physical examination revealed a body temperature of 36.5 °C and blood pressure of 110/70 mmHg. There was a right testicular swelling and tenderness. There was no color change on the scrotum. His laboratory findings were: leukocytes 8470/mm3, hemoglobin 13.4 g/dl, thrombocytes 467.000/mm3, ALT (alanine aminotranspherase) 24.7 IU/L (normal range, 7-40), AST (aspartate aminotranspherase) 27.1 IU/L (normal range, 8-41), ESR (erytrocyt sedimentation rate) 19 mm/h, CRP (C-reactive protein) 0.335 mg/dl (normal value, 5 mg/dl), and the Brucella agglutinin titer was positive at 1/1280. The blood cultures of the patient were negative. Sonographic evaluation was performed with a Nemio ultrasound scanner using a 9-12 MHz linear transducer (Toshiba, Tokyo, Japan). Real time scrotal sonography revealed an anechoic cystic lesion with irregular borders and thick wall measuring 31x41x74 mm, and containing low level echoes and with few septa, which replaced almost entire right testis (Figure 1a). The peripheral border of the lesion and the septa were hypervascular on color Doppler sonography suggestive for an abscess (Figure 1b). The right epididimis and entire right testis tissue were also hypervacularised on Doppler sonography consistent with orchi-epididymitis. The left testis was normal on scrotal gray-scale and Doppler sonography. The patient was diagnosed as brucellar orchi-epididymitis with right testicular abscess based on the constellation of laboratory and sonography findings. Antibiotherapy with doxycycline (100 mg twice daily) and streptomycine (1 gr daily) has been initiated for 7 days. However, the diameter of the abscess did not change at the end of 7 days, and we decided to drain the abscess using a fine needle aspiration to reduce the size of lesion and increase the efficacy of medication. The patient received a 6-week course of oral doxycycline (100 mg twice daily) and rifampicin (600 mg once daily), and follow-up scrotal sonography after two months showed complete resolution of the lesion leaving a residual small area of heterogeneity in the right testis (Figure 1c). mitis is very rare, and only eight cases have been reported in the literature to our knowledge.[3-8,10,11] The characteristics of the reported cases are summarized in Table 1. In the acute (a) (b) (c) Discussion Brucellosis, caused primarily by B. melitensis, remains the most common zoonotic disease all over the world, and it is endemic particularly in Mediterranean countries.[1,2,7] Brucellosis is a multisystemic infectious disease which may cause suppurative complications most frequently at the bones and joints. Most common clinical findings of brucellosis are fever, osteoarticular involvement, and sweating. Genitourinary system is the second most common site of focal brucellosis which can appear as orchi-epididymitis or nephritis. Orchi-epididymitis can be seen in 5.7% of affected patients.  Brucellar abscess occurs when the necrosis occurs in the region of granulomatous infection induced by the persistence of the bacteria in macrophages. Testicular abscesses associated with brucellosis in the process of orchi-epididy- Figure 1. (a) Gray-scale sonography image demonstrates a large anechogenic cystic mass with a thick sept (arrow) and pressed testicular parenchyma (asterix). (b) Color Doppler sonography image demonstrates the hypervascularity in the thick sept (arrow head), pressed testicular parenchyma (short arrow) and epididymis (long arrow) resembling orchi-epididymitis. (c) Gray-scale sonography image demonstrates heterogeneous hypoechogenic area (arrows) at the right testis on follow up sonography after 2 months. Kaya F et al. Brucellar Testicular Abscess Case Presenting as a Testicular Mass Table 1. Charesteristics of patients with testicular brucellar abscess Study Fernandez et al. Age Imaging findings Biopsy (years) (US and CDUS) ND Increased testicular size Abscess Serologic Test Culture Treatment Positive Negative Orchiectomy, double drugx Castillo Soria et al. Orchiectomy, ND Complete destruction of testis Abscess Positive Negative Bayram et al. ND Hypoechoic tumor-like lesion NGO STA Positive double drugx B.melitensis Orchiectomy, D+R Gonzalez Sanchez et al. Orchiectomy, ND Hypoechoic tumor-like lesion NGO Positive ND double drugx Kocak et al. Orchiectomy, 32 Hypoechoic tumor-like mass CGI STA Positive Negative Akinci et al. ND Hypervascularity NGO STA Positive C+D B.melitensis Orchiectomy, D+R Koc et al. 42 Hypervascular, thick-walled lesion CGI STA Positive B.melitensis Drainage, D+R Yemisen et al. 43 Hypoechoic, No biopsy STA Positive Negative D+R Abscess STA Positive Negative Drainage, heterogeneous, cystic lesion Case in this study Anechoic cystic lesion with 42 hypervascularization in thetestis and epididimis D+R+S C+D: Ciprofloxacin+doxycycline; CDUS: Color Doppler sonography; CGI: Choronic granulamatous inflammation; D+R: Doxycycline+rifampicin; D+R+S: Doxycycline+rifampicin+streptomycine; ND: Not defined; NGO; Necrotizing granulomatous orchitis; S+D: Streptomycine + doxycycline; STA: Standard tube agglutination; US: Ultrasonography. x: Possibly doxycycline and rifampicin. phase of brucellosis, blood cultures are positive in only 1030% of patients and clinical findings are generally nonspecific. Incidence of blood culture positivity decreases by the duration of infection. The main diagnostic criteria for brucellosis are high agglutination titers (>1/160) for anti-Brucella antibodies using the standard tube agglutination (STA) test, and the presence of the clinical signs and symptoms of brucellosis. In chronic brucellosis the STA test can reveal negative or very low agglutination titers (<1/160). In some cases of brucellosis, anemia (35-55%) or leukopenia (21%) can be observed. In our case, the leukocytes and hemoglobin values were within normal range and there was no abnormal result in other blood tests as well. The diagnosis of brucellar testicular abscess was established by the positive serologic test results, history of ingestion of unpasteurized dairy product, and the visualization of dense cystic lesion with thick wall on gray-scale sonography and showing hypervascularization in the region of epididymis and around the abscess on Doppler sonography. The main differential diagnosis of testicular brucellar abscess is a necrotic tumor. Failure to diagnose the abscess appropriately can lead to unnecessary orchiectomy in patients with delayed diagnosis due to large suspicious lesions which cause partial or total destruction of the testis. Six patients underwent orchiectomy with combined antibiotic treatment among the reported eight cases in the literature. [3-8] A conservative treatment with antibiotics or combined antibiotic therapy and drainage is usually adequate in the treatment of brucellar testicular abscess. Two patients[10,11] underwent conservative treatment with antibiotics and drainage as in our patient. In the report of Yemisen et al. orchiectomy was offered to the patient in the one month follow up because of no change in gray-scale sonographic findings but patient did not accept the surgery. In the report of Koc et al., the testicular abscess was diagnosed based on color Doppler sonography and the drainage and the administration of combined antibiotic therapy were applied. In our case, the initial clinical diagnosis was also testicular abscess upon clinical, laboratory and color Doppler sonography findings. We believe that color Doppler sonography has an important role for the diagnosis of abscess as it shows hypervascularization at the region of orchi-epididimitis. Therefore, brucellar testicular abscess can be accurately diagnosed by color Doppler sonography on the basis of hypervascularization in the region of epididymis and testis (i.e. orchi-epididymitis) in a patient with consistent clinical and laboratory findings. Color Doppler sonography was per- Turk J Emerg Med formed in two reported cases[8,10] and hypervascularization in the testicular and epididimal region was the main finding in both examinations. In conclusion, testicular abscess is a very rare complication of brucellosis which can be under or misdiagnosed. The initial diagnosis of brucellar testicular abscess can be considered in patients with a history of unpasteurized dairy products consumption, clinical findings and serologic test results, and suggestive color Doppler sonography findings for orchi-epididymitis. Color Doppler sonography is instrumental in the clinical diagnosis when the gray-scale sonography findings resemble the necrotic testicular tumor. simulating testis tumor. Int J Urol 2004;11:683-5. 4. Fernández Fernández A, Jiménez Cidre M, Cruces F, Guil M, Bethencurt R, Dehaini A, et al. Brucellar orchitis with abscess. [Article in Spanish] Actas Urol Esp 1990;14:387-9. [Abstract] 5. Castillo Soria JL, Bravo de Rueda Accinelli C. Genital brucellosis. A rare cause of testicular abscess. [Article in Spanish] Arch Esp Urol 1994;47:533-6. [Abstract] 6. Bayram MM, Kervancioğlu R. Scrotal gray-scale and color Doppler sonographic findings in genitourinary brucellosis. J Clin Ultrasound 1997;25:443-7. 7. González Sánchez FJ, Encinas Gaspar MB, Napal Lecumberri S, Rajab R. Brucellar orchiepididymitis with abscess. [Article in Spanish] Arch Esp Urol 1997;50:289-92. [Abstract] Conflict of Interest 8. Akinci E, Bodur H, Cevik MA, Erbay A, Eren SS, Ziraman I, et al. A complication of brucellosis: epididymoorchitis. Int J Infect Dis 2006;10:171-7. The authors declare that there is no potential conflicts of interest. 9. Cosme A, Barrio J, Ojeda E, Ortega J, Tejada A. Sonographic findings in brucellar hepatic abscess. J Clin Ultrasound 2001;29:109-11. References 10.Koc Z, Turunc T, Boga C. Gonadal brucellar abscess: imaging and clinical findings in 3 cases and review of the literature. J Clin Ultrasound 2007;35:395-400. 1. Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med 2005;352:2325-36. 2. Gür A, Geyik MF, Dikici B, Nas K, Cevik R, Sarac J, et al. Complications of brucellosis in different age groups: a study of 283 cases in southeastern Anatolia of Turkey. 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